Surg Today DOI 10.1007/s00595-012-0464-6
ORIGINAL ARTICLE
Functional outcomes and quality of life in patients treated with laparoscopic total colectomy for colonic inertia Omar Vergara-Fernandez • Rabı´ Mejı´a-Ovalle • Noel Salgado-Nesme • Nathalie Rodrı´guez-Dennen • Javier Pe´rez-Aguirre • Vı´ctor Hugo Guerrero-Guerrero Juan Carlos Sa´nchez-Robles • Miguel Angel Valdovinos-Dı´az
•
Received: 9 July 2012 / Accepted: 2 October 2012 ! Springer Japan 2013
Abstract Purpose To assess the functional outcomes and quality of life in patients with laparoscopic total colectomy for slowtransit constipation (STC). Methods All patients undergoing laparoscopic colectomy with ileorectal anastomosis for colonic inertia at two referral centers were analyzed. Their preoperative, intraoperative and postoperative details were recorded with a one-year follow-up. Their quality of life was assessed using the SF-36 questionnaire. Results Between 2004 and 2007, 710 patients were evaluated. Eight female patients (1.1 %) fulfilled the criteria for STC without obstructive defecation syndrome. Their mean age was 38 years ± 15 (range from 22 to 62). The conversion rate was 12.5 %. The morbidity rate was 37.5 %, and mortality was nil. The preoperative abdominal pain was 6.6 ± 0.3 and had decreased to 3.6 ± 2.3 postoperatively (P = 0.008). At 1 year, the defecation frequency per week had increased from 0.84 ± 0.24 to 6.75 ± 3.4 (P = 0.001). Three patients developed
O. Vergara-Fernandez (&) ! R. Mejı´a-Ovalle ! N. Salgado-Nesme ! N. Rodrı´guez-Dennen Division of Surgery, Colorectal Surgery Service, Instituto Nacional de Ciencias Medicas y Nutricion ‘‘Salvador Zubiran’’, CP 14000 Mexico City, Mexico e-mail:
[email protected] J. Pe´rez-Aguirre ! V. H. Guerrero-Guerrero ! J. C. Sa´nchez-Robles Colorectal Surgery Service, Central Military Hospital, Mexico City, Mexico M. A. Valdovinos-Dı´az Gastroenterology Department, GI Motility Disorders Service, Instituto Nacional de Ciencias Medicas y Nutricion ‘‘Salvador Zubiran’’, Mexico City, Mexico
nocturnal leakage (37.5 %). Eighty-eight percent of the patients recommend the procedure. All parameters of the SF-36 questionnaire had improved at the one-year followup examination. Conclusion Laparoscopic colectomy for slow-transit constipation is safe and increased the number of evacuations per week. Although nocturnal leakage may occur, these patients experience improvements in their quality of life. Keywords Colon ! Inertia ! Laparoscopy ! Colectomy ! Quality of life
Introduction Constipation is a common symptom affecting between 2 and 34 % of the general population in Western countries. This disease is responsible for over 2.5 million medical consultations per year in the United States, and predominantly affects females with risk factors such as physical inactivity, low socioeconomic status, a limited education, depression, and those with a history of sexual abuse [1, 2]. Constipation has been defined as the incapacity to evacuate the bowel in a complete and spontaneous form at least three or more times a week. In addition, most patients with constipation present one or more of the following symptoms: hard infrequent stools, excessive straining, a feeling of incomplete evacuation, excessive time attempting to evacuate or as dissatisfaction with defecation [3–6]. This condition has been classified in three types: (1) constipation with normal colonic transit, (2) constipation with slow colonic transit, and (3) outlet obstruction. Slowtransit constipation (STC) is characterized by a loss in the motor activity of the bowel, occurring more frequently in
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young females, and is commonly manifested by one or fewer bowel movements per week. The diagnosis is made with a colonic transit study showing a delay in the emptying of the radiopaque markers, and excluding the existence of outlet obstruction [3, 5, 7, 8]. In cases that are resistant to medical management, total colectomy has proven to be a definite treatment, with success rates up to 85 %. With the advent of minimally invasive techniques, this surgery has been proven to be safe and to have greater short-term benefits [5, 9–20]. The objective of our study was to demonstrate the functional results, morbidity and the changes in the quality of life with a 1-year follow-up in patients who underwent a laparoscopic total colectomy for colonic inertia.
Materials and methods We included all patients diagnosed with constipation due to slow intestinal transit from January 2004 to December 2007 at two referral centers in Mexico City. All patients were diagnosed with constipation and slow colonic transit according to the Roma II criteria [6]. The colonic transit studies were performed with radiopaque markers and were defined as positive when 20 % or more of the markers were localized in the colon after 96 h. Prior to surgery, the small-bowel transit time with barium was examined in all patients (normal \5 h), as well as defecating proctography and anorectal manometry [2]. Patients with obstructive problems of the pelvic floor were excluded from the study. All surgeries were performed by colorectal surgeons using a laparoscopic approach. The quantification of pain was analyzed using a Visual Analog Scale rating from 0 to 10, in which no pain was correlated with 0 and severe pain with a 10. Detailed written informed consent was obtained from all of the subjects after a full explanation of the procedure. All patients received mechanical intestinal preparation with polyethylene glycol, and also received per oral (erythromycin and metronidazol) as well as intravenous (ceftriaxone and metronidazol) antibiotics prior to the procedure as antibiotic prophylaxis. The surgery was performed with five port access and ultrasonic coagulation shears for the colonic dissection. The vascular pedicles were transected with staples and vessel sealing devices. The resection of the colon was performed at the rectosigmoid junction with a laparoscopic intestinal stapler. The anastomosis was done using a 29 circular stapler. All patients were subjected to a hydropneumatic test to verify the hermeticity of the anastomosis. The patients’ quality of life was evaluated using an SF36 questionnaire which included questions related to physical function, role physical, physical pain, general
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health, vitality, social function, role emotional and mental health. Once the questionnaire was applied to the patients, a summary calculation and a linear transformation were performed to obtain a score within a scale from 0 to 100 [21, 22]. The symptoms, number of evacuations, laxative use and the quality of life were all evaluated prior to the surgery, as well as at a 1-year follow-up examination. All patients were asked if they would recommend the procedure. Statistical analysis The results are expressed as the medians or means ± standard deviation. The Chi-square test was used for nonparametric variables and Fisher’s exact test was used for the quantitative measurements. All statistical calculations were performed with the aid of a computer software program (SPSS version 16, SPSS Inc. Chicago Illinois, USA). A P value \0.05 was considered to be significant.
Results Between 2004 and 2007, 710 patients were evaluated for constipation in two referral centers. Eight female patients (1.1 %) fulfilled the criteria for STC without obstructive defecation syndrome. All patients were included after a failure of medical treatment. The mean age of these patients was 38 years ± 15 (range 22–62 years). The anastomoses performed were end-to-side in three and endto-end in five patients. A conversion to open surgery was needed in one of the patients (12.5 %). None of the patients had anastomotic leakage detected by the hydropneumatic test performed during surgery. With regard to the surgical variables, the median skin incision length was 5 cm (range 4–7 cm), the median length of the operation was 240 min (range 150–320 min), and the median intraoperative blood loss was 100 ml (range 50–180 ml). Abdominal distention was present in seven patients before the surgery and in three after the surgery (87.55 vs. 37.5 %, P = 0.034). The quantification of preoperative abdominal pain was 6.6 ± 0.3 (range from 4 to 8) and decreased to 3.6 ± 2.3 postoperatively (range from 2 to 8; P = 0.008). The number of patients with nausea prior to surgery was six, and had decreased to two after the procedure (P = 0.157). Vomiting during a 1-week period was reported by four patients before the surgery and by only one patient after surgery (P = 0.034). None of the patients was incontinent to gases, liquids or solid stool before or after the procedure. Three patients presented with nocturnal leakage after the surgery (37.5 %). The median bowel movements per week, the quantity of laxatives used per day and the percentage of patients who
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used maneuvers to assist evacuation are shown in Table 1. The median length of hospital stay was 5 days, with a range of 4–15 days. The global morbidity was 37.5 %, among which were one case of intestinal subocclusion, one anastomotic leak and one internal hernia. These last two patients required a new surgical intervention (25 %). The intestinal subocclusion was managed conservatively. There was no mortality. The median small-bowel transit time was 120 min (range 80–480), and it was delayed in one patient (480 min). This patient manifested repetitive cases of subocclusion (12.5 %). Eighty-eight percent of our patients reported an improvement of their symptoms and would recommend the procedure. An evaluation of their quality of life before and 1 year after the surgery is shown in Table 2.
Discussion The majority of patients with constipation are treated with simple measures such as changes in their diet and the use of laxatives; however, when the condition proves to be recalcitrant, it is imperative to rule out secondary causes, among which may be metabolic, organic or pharmacological factors. Chronic primary constipation is present in up to 9.9 % of patients; these are the ones who must be evaluated for the possibility of surgical treatment. Total abdominal colectomy with ileorectal anastomosis is the Table 1 Number of bowel movements, laxatives used and defecatory maneuvers used before and after surgery Outcomes
Before surgery
One-year follow-up
P
No. of evacuations per week*
0.84 ± 0.24 (1–2)
6.75 ± 3.45 (1–12)
0.001
Laxatives used per day*
4.12 (3–9)
0.37 (0–3)
0.0001
% patients with auxiliary defecatory maneuvers
62.5
25
0.157
* Mean (range)
Table 2 Evaluation of the quality of life before and after surgery using the SF-36 questionnaire Before surgery
One-year follow-up
P
Physical function
37.5 ± 17.7
88.7 ± 10.2
0.0001
Role physical
37.5 ± 17.6
83.3 ± 14.4
0.002
Bodily pain
21.6 ± 20.2
81.2 ± 24.6
0.009
General health
18.5 ± 17.9
77.12 ± 18.88
Vitality
10 ± 13
83 ± 14.4
0.001 0.0001
Social function
18.7 ± 23.9
85.7 ± 28
0.001
Role emotional
37.5 ± 20.9
93.7 ± 12.5
0.0001
Mental health
41.2 ± 25.03
87.14 ± 12.8
0.001
surgical procedure that has demonstrated to have the best results in such patients [7, 9–11, 23, 24]. Laparoscopic colonic surgery has been clearly demonstrated to have postoperative benefits. Especially in the case of young patients with colonic inertia, as was the case in our series, this approach also has cosmetic benefits. Also, there is the theoretical advantage of decreasing the number of adherences, post-incisional hernias and better long-term preservation of fertility [13–20]. Pitarsky et al. assessed the functional outcomes of 50 patients with open total colectomy and ileorectal anastomosis, with a follow up of 106 months. All patients showed excellent results, although 20 % of patients required hospitalization due to intestinal occlusion and 10 % underwent a new surgical procedure [12]. In our series, there was one case of intestinal subocclusion and one internal hernia. The first patient was successfully treated with a conservative approach and the latter required a new intervention. Our global rate of reinterventions was 25 %. Regarding the overall postoperative satisfaction, the results of several studies were variable, reporting figures ranging from 39 to 100 % [9, 10, 24]. One year after the surgery, 88 % of our patients reported an improvement of their symptoms and mentioned that they would recommend the procedure. Knowles et al., in a review of 32 studies, found that the surgery was successful in 86 % of cases by evaluating the degree of global satisfaction. The number of bowel movements after the surgery was 2.9/week, with a range from 1.3 to 5/week, and with the presence of diarrhea in 14 % of patients. In our series, the mean number of evacuations per week was 6.7, which was significantly higher compared with the preoperative status. The percentage of patients with fecal incontinence in this review was 14 %, while none of our patients were incontinent before or after the procedure. They found that the results were worse in patients with generalized gastrointestinal dysmotility disorders presenting with recurrent constipation, intractable diarrhea and intestinal obstruction affecting up to 70 % of the colon [24]. One patient in our series, with delayed small bowel transit, presented with repetitive episodes of subocclusion. As has been demonstrated in other series, we consider that the selection of patients for this surgery is of the utmost importance, reinforcing the significance of excluding patients with slow small bowel transit for this procedure. The mortality rate reported in the literature regarding this surgery ranges from 0 to 15 %. A group of authors concluded that, due to inadmissible morbidity and mortality rates, this surgery is not advisable, and should not be performed [25]. Despite the fact that there was one anastomotic leakage, there was no mortality in our series. The patient presented the anastomotic leakage on the fifth postoperative day and was treated with closure, a proximal
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loop ileostomy, antibiotics and drainage. The stoma was closed 2 months later without any complications once the absence of leakage was verified. We consider that an immediate identification of this type of complications leads to better results. Concerning the functional results, the number of bowel movements increased from 0.85 to 6.75 per week, which was a statistically significant difference. The use of postoperative laxatives decreased from 4.12 to 0.37. Although there was an improvement in terms of the use of defecatory maneuvers, we did not observe a statistically significant difference. These results are similar to those reported by Mollen [26]. Symptoms such as abdominal distention, pain and vomiting all improved after the surgery. Despite the episodes of nocturnal leakage that occurred in three of our patients, we reinforce the fact that none presented with fecal incontinence during the day. This differs from the results reported by Zutshi et al. [11], who showed a decrease in symptoms such as pain and abdominal distention, but the persistence of nausea in up to 37 % of patients, vomiting in 50 %, and incontinence in 40 %. The SF-36 questionnaire is an instrument that has been considered as a standard tool in the evaluation and validation of the quality of life, and has previously been used in patients with total colectomy due to colonic inertia [27, 28]. The preoperative quality of life in our patients was poor, obtaining a median below 50 in all values. As observed in Table 2, there was an improvement in all evaluated parameters 1 year after the surgery. Our results contrast with those reported by Thlaer and colleagues [27], where there was a decrease in the role physical, social function and role emotional parameters, despite the improvement in constipation. In a study by FitzHarris et al. [28], the quality of life was adversely affected by the presence of abdominal pain, diarrhea and fecal incontinence following the procedure. Other less invasive and new treatments, such as sacral neuromodulation or percutaneous tibial nerve stimulation, have been described for patients with severe constipation; however, these are not widely available, are expensive and more studies are needed to establish their efficacy [29–31]. In conclusion, in our series we observed an improvement in associated symptoms such as abdominal distention, pain and vomiting, without the presence of fecal incontinence. Both the number of evacuations per week and the number of laxatives used daily were improved by the procedure. Eighty-eight percent of our patients recommended this surgery 1 year after the procedure, and observed an improvement in all parameters regarding their quality of life. Although there was one case with an anastomotic leak, there was no mortality in our series. Based on our results, we consider that the use of minimally
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invasive total colectomy with an ileorectal anastomosis is the procedure of choice in patients with colonic inertia, and should be performed by experts in laparoscopic colorectal surgery. Conflict of interest Dr. Omar Vergara-Fernandez and co-authors have no conflict of interest.
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